PHYSICIAN’S RELEASE TO RETURN TO WORK FORM
Employee’s Name:
Date:
Physician’s Name:
Telephone #:
To be completed by Physician
After reviewing the attached job description and the specific tasks within the
job description please complete either (A) or (B) as appropriate and sign and
date below.
(A) The above named employee has been released by the above named
_______________(Date)
physician to return to Full Duty as of
with NO RESTRICTIONS.
(B) The above named employee has been released by the above named
physician to Return to Work on
___________(Date) WITH THE
FOLLOWING RESTRICTIONS through __________(Date):
Check applicable boxes and provide limitations/restrictions.
† Lifting (Max weight in lbs) _________lbs. † Walking ___________ hours per day
† Repetitive Lifting ___________lbs.
† Standing ___________ hours per day
† Carrying _____________lbs.
† Sitting ___________ hours per day
† Pushing/pulling ___________lbs.
† Crawling ___________ hours per day
† Pinching/Gripping ___________lbs.
† Kneeling ___________ hours per day
† Reaching over head
† Squatting ___________ hours per day
† Reaching away from body
† Climbing ___________ hours per day
† Repetitive Motion Restrictions:
† Other Restrictions:
These limitations/restrictions are:
† Temporary limitations/restrictions
† Permanent limitations/restrictions
IF THE ABOVE RESTRICTION CONSTITUTE MODIFIED DUTY AND SUCH DUTY IS NOT
AVAILABLE, IT IS ASSUMED THAT THE EMPLOYEE WILL BE SENT HOME RATHER THAN
RETURN TO WORK. My signature indicates that I have read and understand the employee’s
job description and the listed tasks within the job description and that my findings are based
on my medical assessment of this employee’s physical capabilities as compared to the
essential functions of the job.
Physician’s Name (Please Print):
Physician’s Signature:
Date:
I AGREE THAT:
I will follow through with all of the restrictions listed above. I will notify my supervisor of
any departure from these restrictions.
Employee’s Signature:
Date: